Basrah Journal of Surgery

Majeed H Alwan
FRCS, FRACS, FACS, Gastrointestinal and General Surgeon, New Zealand
5 Tamworth Place, Gate Pa, TAURANGA, NEW ZEALAND. malwan@paradise.net.nz
Abstract
The traditional treatment of patients with adenocarcinoma of the rectum involved some form of
radical surgery in fit patients followed by radiotherapy, or chemotherapy, or both depending on
the stage of the disease and the general condition of the patient. More recently the emergence
of neoadjuvant chemoradiotherapy (CRT) has fundamentally changed the management of
these patients. Although initially it was recommended for locally advanced disease in an attempt
of downstaging the tumour to make it resectable, the indication in using this modality had been
widened.
In clinical trials, up to 30% complete pathological response (pCR) of tumours have raised the
question as to whether surgery, especially radical could be avoided in certain group of patients.
A trial of omission of surgery in this group of patients has shown favourable long-term results.
This article is an outline of the emerging factors for achieving complete pathological response;
the non-operative or the minimal surgery strategies, methods of predicting response to chemoradiotherapy,
and means of judging the complete pathological response.

Incision hernia remains a frequent complication of abdominal surgeries with a reported
incidence of (2-20%). Repair of large incision hernia is a difficult surgical problem with short and
long term complications, severity of these complications are related in part to the type of
operative technique adopted.
The aim of this study is to evaluate the outcome of repair of large incision hernia with the (onlay
tension free) mesh technique.
This is a retrospective study includes 46 patients who underwent mesh repair for large incision
hernia during the period from January 1997 to December 2004. The operations were done by
the same surgeon and by the same procedure (i.e; onlay tension free polypropylene mesh with
two points fixation). Data regarding relevant patients with big ventral incision hernia with (onlaymesh
repair) in Basrah teaching hospital and private hospital were revised. The presenting
condition, hernia description, associated systemic and local factors, procedure of repair and
follow up duration were all taken in consideration. Possible complications like; hematoma,
seroma, wound infection, intestinal obstruction and enterocutaneous fistula were recorded and
discussed once they occurred. The follow up period ranged from 4 to 21 months.
Forty six patients were included in the study: 20 females and 26 males with median age of 50.5
year (range 35-68 year). Eleven patients (23.91%) were overweight and had body mass index
"BMI" equal to more than 30, four patients (8.69%) had controlled diabetes mellitus, five
(10.86%) had controlled hypertension and two (4.34%) suffered from chronic obstructive air way
disease, there were eleven smokers (23.91%). Sixteen patients made regular visits that
extended up to 12 months, 12 patients made regular visits up to 6 months, one made regular
visits up to 18 month mainly due to partial intestinal obstruction., one patient was followed-up to
17 month because of multiple wound sinuses while 8 patients made irregular visits up to 21
month due to causes other than the hernia, eight patients lost from follow-up after 4 months.
The original operation was bowel related in 18 cases, gynecological in twelve,
hepatopancreatobiliary in 10, repair of paraumbalical hernia in six patients. The old incisions
were long midline in 23 cases, paramedian in 17 and transverse in six patients. The main
postoperative complications were seroma formation (13.04 %), wound haematoma (6.52 %),
wound infection (4.34 %). no recurrence of hernia and no enterocutanous fistula were reported
during our follow-up period.
In conclusion, tension free onlay mesh repair is a feasible operative procedure for repair of large
incision hernia with no significant major morbidity.

Four hundred cases of laparoscopic cholecystectomy candidates were
prospectively followed at the time of surgery by obtaining a data sheet for the
patient’s age, sex, time from the introduction of ports till decision of conversion
and the cause of conversion if present in two years (2006 & 2007) period.
From 400 laparoscopic cholecystectomy, 20 conversions were obtained and the
causes were; wide cystic duct, empyema of the gall bladder, severe obesity, liver
tumor, abnormal position of gall bladder, vascular variation and dense adhesions
with disturbed anatomy. The percentage of conversion was 5%. Eight conversion
cases were males from the total 45 male patients underwent laparoscopic
cholecystectomy. Twelve cases were females out of 355 female patients
underwent laparoscopic cholecystectomy. The percentage of conversion for male
patients was 17.7% while in female patients was 3.3%. Our results showed that
the conversion rate in this study was 5% and the most common cause for
conversion is dense adhesions. No biliary duct injury or severe bleeding that
need conversion is found in this study and the rate for conversion is higher in
male patients.

This study aimed to assess the accuracy of histopathology, brush cytology, and
urease test in the diagnosis of Helicobacter pylori and to evaluate the effect of test
duration on the sensitivity and specificity of positive urease test for the detection of H.
pylori.
Fifty patients [25 patients with gastritis group A and 25 patients with duodenal ulcer
group B] selected from those attending endoscopy unit for dyspeptic symptoms, were
enrolled in the study. Four endoscopic biopsies were taken from each patient. One
biopsy from each of antrum and body were obtained for urease test (Urease test was
read at 30 min, 1, 4 and 24 hour after biopsy insertion into the reagent), and one
biopsy from each of antrum and body were used for histopathological examination.
Antral brush cytology was taken also from each patient. The patients were considered
H. pylori positive when minimum concordances of 2 out of 3 tests (Histopathology,
brush cytology, and urease test) were positive.
Fourteen patients were positive for H. pylori in group A, in comparison to seventeen
patients in group B. The sensitivities of the histopathological examination, brush
cytology, and urease test at 24 hours in group (A) were 58%, 79%, and 93%
respectively. Corresponding figures for the specificity were 100%, 91%, and 46%
respectively. While in group (B) the sensitivities were 82%, 82%, and 100% and the
specificities were 100%, 100%, and 88% respectively.
It is concluded that among the invasive methods, the association of the urease test
with brush cytology constituted the best choice for confirming the diagnosis of H.
pylori, due to the high sensitivity of the urease test and high specificity of brush
cytology.

During one year period, 21 newly diagnosed patients with different malignant bone tumors were
subjected to this study, 52.4% (11) of them were males & 47.6% (10) were females with a mean
age of 50.2 years. Detailed history & physical examination were taken including the age, sex,
the pathological type of the tumor, whether it is a primary or secondary & the site of the tumor,
the existence of bone pain, fever, weight loss, pallor, pathological fractures, neurological deficit,
any adjuvant treatment the patient had been put on, the existence of sickle cell disease, diabetes
mellitus and any history of a previous surgery. All cases were subjected to the following
tests: complete blood count (CBC) including the estimation of erythrocyte sedimentation rate
(ESR) & reticulocyte count, estimation of lactate dehydrogenase(LDH) & alkaline phosphatase
(ALP) enzymes & serum calcium. All cases were subjected to bone marrow examination including
both aspirate & trephine biopsy (with its touch imprint). Smears & sections were examined
thoroughly to assess marrow status with emphasis on the existence of bone marrow necrosis
(BMN).
Results showed that 19.1 % of cases had bone marrow necrosis. Their mean age was 50.25
years, with equal sex distribution, half of them had primary tumors, and 75 % of them had their
tumors situated in the spine. Clinically: all of them had weight loss, fever & bone pain while 75
% of them had pathological fractures. The mean values of the investigations done for them
were: Hb 94 g/L, PCV 0.29, reticulocyte count 2.43 %, WBCs 14.75 x 109/L. Peripheral blood
film for all showed leuco-erythroblastic picture. They showed an elevated mean serum LDH
(307.50 IU/L) & ALP (116.06 IU/L) levels.
Cases that showed no evidence of BMN constituted 80.9 % of total. They had a mean age of
5.15 years. 52.9 % were males while 47.1 % were females. Just more than half of cases (52.9
%) had primary while 47.1 % had secondary type of tumors & 47.05 % of them were located in
the spine. Clinically all of them had bone pain, 94.1 % had weight loss, 52.9 % pathological fractures,
29.4 % pallor & 23.5 % had fever. Their mean laboratory values were: Hb 108.1 g/L, PCV
0.33 %, reticulocyte count 1.36 %, WBCs 7.11 X 109/L, LDH 214.88 IU/L, ALP 83.48 IU/L.
Comparative study between cases with BMN & those without showed a significant relationship
between the following parameters & the presence of BMN at a level (p<0.05): fever, leukocytosis,
reticulocytosis, and high LDH levels. These results were comparable with some & contradicting
with other studies.
The paucity of studies in this field created difficulties to relate the results of this study to others,
especially in our Country. Further studies in the same field will probably clarify.
In conclusion, bone marrow necrosis, is not uncommon among primary & secondary malignant
bone tumors. It is associated with severe clinical-pathological features that may reflect a poor
outcome. Prolonged, follow up studies are in need to clarify this point.

A serological study has been done in Al-Nassiriyha, southern Iraq, from December 2006 to
August 2007 designed to determine the frequency of anti-cyclic citrullinated peptide antibody
(anti-CCP) in a group of patients with rheumatoid arthritis for specific period of time compared
with other rheumatic diseases and healthy controls. Also to show the diagnostic value of
anti-CCP antibody in relation to other markers [rheumatoid factor (RF), antinuclear factor (ANF),
C-reactive protein (CRP) and cytokines such as interleukin–6 (IL-6), tumor necrosis factor–α
(TNF-α)] to discriminate between those patients with and without RA.
Blood samples were taken from 121 patients with rheumatoid arthritis, 88 patients of other
rheumatic diseases from AL-Hussein Teaching Hospital in AL-Nassiriyah and 120 healthy
controls from medical personnel and school students who were healthy. All the information was
taken from the patients and controls.
An Enzyme-linked immunosorbent assay was used for estimation of anti-CCP, IL-6, TNF-α and
slide agglutination test for the estimation of RF, CRP and ANF. The seropositivity to anti-CCP in
RA patients group was 61.2% among them 23% with low levels of anti-CCP, 25% with
moderate levels and 51.3% with high levels (> 60 units /ml.).The high levels of anti-CCP persist
for long durations up to 10 years (54.7%). However, anti-CCP was rarely detected among non-
RA rheumatic diseases and healthy controls (2.3% and 2.5% respectively). Anti-CCP showed
the greater specificity (97.6%) and sensitivity (61.2%) compared to the other marker used in this
study. The overall agreement between the tested parameters in their ability to detect RA patient
was higher for anti-CCP combined to IL-6 (91.7%) in comparison to the effect of other markers
combination. Although anti-CCP was more common in RA patient with 2-10 years duration of
illness, anti-CCP, IL-6 and TNF-α positivity as estimated by ELISA were persistently with high
titers regardless the duration of illness. The majority of RA patients with high anti-CCP levels
were among stage three of clinical RA. Smoking has a positive relation to the increased levels
of all tested parameters compared to the non-smokers.

Streptococcus agalactiae was isolated from eight out of 42 cases of uterine tumors and
endometrial hyperplasia from inpatients underwent total abdominal hysterectomy in Basrah
Maternity and Child Hospital, due to irregular vaginal bleeding not responding to medical and
hormonal treatment. Six isolates were from uterine tumors, and two from endometrial
hyperplasia. Isolates were identified by being Gram positive, negative for catalase, giving
positive CAMP test, ability to grow in 6.5% NaCl but not 40% Bile salts and resistance to
Bacitracin.
In vitro studies were conducted to investigate virulence factors of isolated S. agalactiae by
testing their ability to produce haemolysin, yellow pigmentation, capsule, resistance to
tetracycline which is indicative for the existence of sialic acid (antiphagocytosis material).
Measurement of the content of sialic acid and lipotechoic acid revealed differences between
isolates.
All isolates, were able to adhere to plastic surfaces and formation of biofilms in both neutral
(pH=7) and acid (pH=4.5) media. The present study has recorded for the first time, resistance of
four isolates of S. agalactiae (50%) to Vancomycin. This finding is worrisome from the clinical
point of view, as these isolates may become a potential source for transmission of Vancomycin
resistance to other bacteria.

This study aimed to describe dactylitis in a cohort of patients resident in Kuwait with psoriatic
arthritis followed prospectively in our Rheumatology clinic and identify whether dactylitis is
associated with a worse outcome in patients with psoriatic arthritis.
Between 2005 and 2008, (53) patients with psoriatic arthritis in Kuwait were followed
prospectively every two months intervals and all patients files information were searched for
patients with dactylitis. Descriptive statistics were used to describe the population and x2 tests to
relate dactylitis to radiographic changes.
Dactylitis was documented in 32 patients (59%); 70% most of the cases were recorded at
presentation to the clinic. Dactylitis affected feet only in 63% of cases, hands only in 12%, and
both hands and feet in 5%. Recurrent dactylitis occurred in 36% of the patients. Increased
radiological progression was noted in digits showing dactylitis compared with those without
dactylitis (54% v 31%, respectively; p<0.0001).
It is concluded that dactylitis is common among patients with psoriatic arthritis resident in
Kuwait. It most often affects the feet, in an asymmetrical distribution. It is associated with a
greater degree of radiological damage than occurs in digits not affected by dactylitis.

Laparoscopic cholecystectomy is currently considered the gold standard for the managment of
gallbladder stones. Many hospitals have employed short stay wards for monitoring patients after
surgery. The meaning of the early discharge as true outpatient surgery is controversial. To
achieve this objective there is a need to shorten the hours of hospital stay by: Appropriate
selection criteria and discharge protocol, Peroperative technical modification and manipulation,
Procedures to control pain, nausea and vomiting. This study was carried at Endosurgery
Centre, Ibensena University Hospital, Sirte, libya.

Twenty five patients underwent auto-transplantation surgery. Seventeen were females and 8
males. Preoperative PA films were taken for each case for localization of impacted canine. Eleven
were palatal impacted and 14 were labially impacted. The technique used is shifting technique
and OPG. The status of surrounding tissues was evaluated radiographically. No case was
associated with any pathology and complete mature root formation. The average age of patients
ranged from 20 to 35 years. In most of them, there was a retained deciduas teeth.

The aim of this study was to determine the impact of phenol injection on the outpatient
treatment of the sacrococcygeal pilonidal sinus disease. A prospective analysis was taken of
forty patients between June 2002 to June 2006 as an outpatient. Age, sex, state of sinuses at
initial presentation & the recovery time was analyzed. Phenol injection applied on 40 patients,
37 males & 3 females. Forty percent of the patients required one injection while 55 % of the
patients had two applications. The recovery time was between 1-3 months. Recurrence was
observed in 15% (6 patients). Phenol treatment is simple, easy & inexpensive method that can
applied on an outpatient basis, decreasing both recurrence rate & the morbidity.

This study aimed to describe the tubularized incised plate (TIP) urethroplasty method for distal
hypospadias repair and to describe certain technical aspects to decrease the incidence of
complications such as meatal stenosis and urethrocutaneous fistula.
Tubularized incised plate urethroplasty was undertaken in 25 patients in the last three years.
The age of patients ranged from one to 7 years. Three cases had undergone a previous repair.
Certain technical points were strictly adhered to during the TIP urethroplasty so as to achieve a
normal slit like meatus and to decrease the incidence of meatal stenosis and urethrocutaneous
fistula. The procedure included placement of transurethral catheter which was removed after 7
days. Average follow up was three months. There was complete dehiscence of the repair in two
patients. Meatal stenosis was seen in two cases. Fistula was seen in three patients. The
patients with a successful repair could void with a straight urinary stream in a forward direction
and had a normally situated slit like glanular meatus.
It is concluded that TIP urethroplasty is a simple operation with good cosmetic results. Certain
technical considerations if strictly adhered to, help in preventing complications and achieve a
satisfactory result.

Breast cancer is the most common cancer in Iraq as well as other parts of the world. In
Western world, the progress in public education and screening program had led to early
detection of the disease which led to good prognosis. Appearance of late stages of breast
cancer reflects the need for active screening and public education programs. The aim of this
retrospective study is to report the pattern of breast cancer in 170 women in Kirkuk province in
relation to age, stage of disease at first presentation and histopathology during nine years
period (Jan.1994 – Jan.2003).
This is a prospective and retrospective study underwent at Breast Clinic, Azadi General
Hospital, Kirkuk, Iraq.
Patients were 170 women with histopathological diagnosis of breast cancer. Out of the 170
women with breast cancer (61.7%) presented between ages 20-50 years and (38.1%) between
ages 51-80 years. Regarding stage of disease on first presentation, (62.3%) of the patients had
late stages of the disease (stage III and stage IV) while only (37.6%) presented at early stages
(stage I and stage II). No stage 0 detected in this study. The commonest histopathology was
infiltrating duct carcinoma (74.1%).
In conclusion, breast cancer in Kirkuk is detected in young women and in late stages on first
presentation. These results highlight the need for increased community awareness about breast
cancer and the need for early detection.

In this prospective study, 25 patients with closed tibial shaft fractures were treated by two
different methods of treating fracture tibia ie, external fixation and plating. Thirteen patients were
treated by uniplanar unilateral external fixation device AO/ASIF type and 12 patients treated by
plating.
There were 22 male and 3 female, there age ranges from 12-45 years. Seventeen patients
sustain car accident as a cause of tibial fracture, associated fibular fractures were in 17
patients. There was no case of malunion in both modalities of treatment. Average time of
fracture union with external fixation was 24 weeks.
In external fixation union rate was 46%, delayed union 31% and non union 23%, complications
were pin tract infection 46%, ankle stiffness 31%, algodystrophy 31% and broken schanz
screws in 15.3%. Average time of fracture union with plating was 22.5 weeks.
In plating, union rate was 59%, delayed union 33% and non union 8%; while complications
were superficial infection 8%, deep infection 8% and ankle stiffness 8%. The non union was
100% in the middle 1/3 and 75% was transverse fracture configuration. The degree of soft
tissue injury, fracture site and configuration has a great effect on union, delayed union, non
union and infection also will affect the choice of treatment. In our study we try to evaluate two
different modalities of treatment, which are plating and external fixation as definitive method of
treatment of closed tibial shaft fracture and we try to compare between the 2 as regards of
different aspect like; time of union and complication in each modality and its relation with type of
fracture site, configuration, degree of soft tissue injury, this in turn will guide us to a better or
more proper choice of treatment modality in the future.

NASAL GLIOMA, A CASE REPORT AND LITERATURE
REVIEW���������.Nasal glioma (also known as nasal glial heterotopia) has been used to describe a congenital
benign tumor of the nasal region containing neural tissue. It arises from failure of closure of
foramen caecum at about the third week of gestation. The patient described in this report is
an 18 months old girl who presented with a nasal bridge swelling for three months. The
differential diagnosis included nasal encephalocele, nasal dermoid and epidermoid cysts. All
are due to failure of ectoderm and neuroectoderm embryologic separation. CT scan and MRI
imaging can be used to look for probable concomitant intracranial tumors and the existence of
a connection between nasal tumor and the brain. Surgical resection is the usual method of
managing such pathologies. In this case, an open rhinoplasty approach was used to resect
this mass after the radiologic evaluation was complete.

Tolosa-Hunt syndrome (THS) has been described as a painful, unilateral, partial or total
ophthalmoplegia caused by a nonspecific granulomatous process in the cavernous sinus, the
superior orbital fissure, or the orbital apex. This syndrome should be differentiated from other
lesions involving the cavernous sinus region, such as meningiomas lymphomas, posterior
communicating artery aneurysms, intracavernous carotid aneurysms, both sellar and parasellar
tumors and carotid cavernous fistulae. We report a case of Tolosa-Hunt syndrome in a 39 years
old patient who presented with cranial nerve palsies.
In conclusion, this syndrome should be differentiated from other lesions involving the cavernous
sinus region, such as meningiomas or lymphomas. It should also be distinguished from
ophthalmoplegic migraine and giant cell arteritis.